Transcript Document 7131013

Maintaining and Expanding
Reimbursement Opportunities
in Mental Health:
Medicare as a Benchmark
DPH 2004
Women & Children’s Health Network
Division of Public Health
Chapel Hill, North Carolina
May 12, 2004
Antonio E. Puente, Ph.D.
Department of Psychology
University of North Carolina at Wilmington
Wilmington, NC 28403
DPH 2004
Contact Information
• Websites
– Univ = www.uncw.edu/people/puente
– Practice = www.clinicalneuropsychology.us
• E-mail
– University = [email protected]
– Practice = [email protected]
• Telephone
– University = 910.962.3812
– Practice = 910.509.9371
DPH 2004
Acknowledgments
Department of Psychology, UNC-Wilmington
NCPA Board of Directors, Practice Division, &
Staff
NAN Board of Directors, Executive Directors’
Office, Policy and Planning Committee, &
Professional Affairs and Information Office
Division 40 Board of Directors & Practice
Committee
Practice Directorate of the American
Psychological Association
American Medical Association’s CPT Staff
CMS Medical Policy Staff
2004 Jim Georgoulakis)
Selected IndividualsDPH
(e.g.,
Background
(1988 – present)
 North Carolina Psychological Association (e)
 APA’s Policy & Planning Board; Div. 40 (e)
 American Medical Association’s Current Procedural
Terminology Committee (IV/V) (a)
 Health Care Finance Administration’s Working Group
for Mental Health Policy (a)
 Center for Medicare/Medicaid Services’ Medicare
Coverage Advisory Committee (fa)
 Consultant with the North Carolina Medicaid
Office;North Carolina Blue Cross/Blue Shield (a)
 NAN’s Professional Affairs & Information Office (a)
(legend; a = appointment, fa = federal appointment, e
= elected)
DPH 2004
Purpose of Presentation
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Increase Reimbursement
Increase Range, Type & Quality of Services
Decrease Fraud & Abuse
Provide Guidelines for Professional Services
Maintain Professional Stature Within Psychology
Increase Professional Stature in Health Care, in
general
DPH 2004
Outline of Presentation
• Medicare
• Current Procedural Terminology: Basic
• Current Procedural Terminology: Related
• Relative Value Units
• Current Problems & Possible Solutions
• Future Directions & Problems
• Resources
DPH 2004
Outline: Highlights
• New Codes
• Expanding Paradigms
• Fraud, Abuse; Coding & Documentation
• The Problem with Testing
DPH 2004
Medicare: Overview
• Why Focus on Medicare
• The Medicare Program
• Local Medical Review (policy & panels)
DPH 2004
Medicare: Why
• The Standard
– Coding
– Value
– Documentation
• Approximately 50% for Institutions
• Approximately 33% for Outpatient Offices
• Becoming the Standard for Workers Comp.
• Increasing Percentage for Forensic Work
DPH 2004
Medicare: Overview
• New Name: HCFA now CMS
– Centers for Medicare and Medicaid Services
• New Charge: Simplify
• New Organization: Beneficiary, Medicare,
Medicaid
• Benefits
– Part A (Hospital)
– Part B (Supplementary)
2004
– Part C (Medicare+ DPH
Choice)
Medicare: Local Review
• Local Medical Review Policy
– LMRP vs National Policy
– Location of LMRPs
• Carrier Medical Director
– A Physician-based Model
• Policy Panels
– Lack of Understanding of Their Roles
– Lack of Representation on Such Panels
DPH 2004
Medicare Payment
(since 1993)
• Surgical
– Higher Reimbursement than Cognitive
• Cognitive
– Physician Cognitive Work
– Supporting Equipment & Staff
DPH 2004
Current Procedural Terminology:
Overview
• Background
• Codes & Coding
• Existing Codes
• Model System X Type of Problem
• Medical Necessity
• Documenting
• Time
DPH 2004
CPT: Background
• American Medical Association
– Developed by Surgeons (& Physicians) in
1966 for Billing Purposes
– 7,500+ Discrete Codes
• CMS
– AMA Under License with CMS
– CMS Now Provides Active Input into CPT
DPH 2004
CPT: Background/Direction
• Current System = CPT 5
• Categories
– I= Standard Coding for Professional Services
– II = Performance Measurement
– III = Emerging Technology
DPH 2004
CPT: Applicable Codes
• Total Possible Codes = Approximately 7,500
• Possible Codes for Psychology = Approximately
•
40 to 60
Sections = Five Separate Sections
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Psychiatry
Biofeedback
Central Nervous Assessment
Physical Medicine & Rehabilitation
Health & Behavior Assessment & Management
Possibly, Evaluation & Management
DPH 2004
CPT: Development of a Code
• Initial
– Health Care Advisory Committee (non-MDs)
• Primary
– CPT Work Group
– CPT Panel
• Time Frame
– 3-5 years
DPH 2004
CPT: Psychiatry
• Sections
– Interview vs. Intervention
– Office vs. Inpatient
– Regular vs. Evaluation & Management
– Other
• Types of Interventions
– Insight, Behavior Modifying, and/or
Supportive vs. Interactive
DPH 2004
CPT: Psychiatry (cont.)
• Time Value
– 30, 60, or 90
• Interview
– 90801
• Intervention
– 90804 - 90857
DPH 2004
CPT: Biofeedback
• Psychophysiological Training
– 90901
• Biofeedback
– 90875
DPH 2004
CPT: CNS Assessment
• Interview
– 96115
• Testing
– Psychological = 96100; 96110/11
– Neuropsychological = 96117
– Other = 96105, 96110/111
DPH 2004
CPT: Physical Medicine &
Rehabilitation
• 97770 now 97532
• Note: 15 minute increments
DPH 2004
CPT: Health & Behavior
Assessment & Management
• Purpose: Medical Diagnosis
• Time: 15 Minute Increments
• Assessment
• Intervention
DPH 2004
CPT: Modifiers
• Acceptability
– Medicare = about 100%
– Others = approximating 90%
• Modifiers
– 22
– 51
– 52
– 53
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=
=
=
unusual or more extensive service
multiple procedures
reduced service
discontinued service
DPH 2004
CPT: Model System
• Psychiatric
• Neurological
• Non-Neurological Medical
• Possibly, Evaluation & Management
DPH 2004
CPT: Psychiatric Model
(Children & Adult)
• Interview
– 90801
• Testing
– 96100, or
– 96110/11
• Intervention
– e.g., 90806
– The challenge of New Mexico
DPH 2004
CPT: Neurological Model
(Children & Adult)
• Interview
– 96115
• Testing
– 96117
• Intervention
– 97532
DPH 2004
CPT: Non-Neurological Medical
Model
(Children & Adult)
• Interview & Assessment
– 96150 (initial)
– 96151 (re-evaluation)
• Intervention
– 96152
– 96153
– 96154
– 96155
(individual)
(group)
(family with patient)
(family without
patient)
DPH 2004
CPT: New Paradigms
• Initial Psychiatric
• Next Neurological
• Now Medical
• Medical as Evaluation & Management
DPH 2004
CPT: Evaluation & Management
• Role of Evaluation & Management Codes
– Procedures
– Case Management
• Limitations Imposed by AMA’s House of
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•
Delegates for CMS but not for Private Payers
Health & Behavior Codes as an Alternative to E
& M Codes
The Use of E & M Codes is Accepted by Some
Third Party Reimburses (e.g., MedCost)
– Example; 99201 New Patient
DPH 2004
CPT: Diagnosing
• Psychiatric
– DSM
• The problem with DSM and neuropsych testing of
developmentally-related neurological problems
• Neurological & Non-Neurological Medical
– ICD (or see NAN Paio web page; membership
directory)
– Neurological Code Updates Available by
01.01.03
DPH 2004
CPT: Medical Necessity
• Scientific & Clinical Necessity
• Local Medical Review or Carrier Definitions
of Necessity
• Necessity = CPT x DX
• Necessity Dictates Type and Level of
Service
• Necessity Can Only be Proven with
Documentation
DPH 2004
CPT: Coding Matrices
• EMSCO & Fraud
• Underlying Problem = Medical Decision
Making
• Do not use:
– Coding Matrices
– Grids
– Related Shortcuts
DPH 2004
CPT: Documenting
• Purpose
• Payer Requirements
• General Principles
• History
• Examination
• Decision Making
DPH 2004
Documentation: Purpose
• Medical Necessity
• Evaluate and Plan for Treatment
• Communication and Continuity of Care
• Claims Review and Payment
• Research and Education
DPH 2004
Documentation: Payer
Requirements
• Site of Service
• Medical Necessity for Service Provided
• Appropriate Reporting of Activity
DPH 2004
Documentation: General
Principles
• Rationale for Service
• Complete and Legible
• Reason/Rationale for Service
• Assessment, Progress, Impression, or
Diagnosis
• Plan for Care
• Date and Identity of Observe
• Timely
• Confidential
DPH 2004
Documentation: Basic
Information Across All Codes
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Date
Time, if applicable
Identify of Observer (technician ?)
Reason for Service
Status
Procedure
Results/Finding
Impression/Diagnoses
Disposition
Stand Alone
DPH 2004
Documentation: Chief Complaint
• Concise Statement Describing the
Symptom, Problem, Condition, &
Diagnosis
• Foundation for Medical Necessity
• Must be Complete & Exhaustive
DPH 2004
Documentation: Present Illness
• Symptoms
– Location, Quality, Severity, Duration, timing,
Context, Modifying Factors Associated Signs
• Follow-up
– Changes in Condition
– Compliance
DPH 2004
Documentation: History
• Past
• Family
• Social
• Medical/Psychological
DPH 2004
Documentation:
Mental Status
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Language
Thought Processes
Insight
Judgment
Reliability
Reasoning
Perceptions
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DPH 2004
Suicidality
Violence
Mood & Affect
Orientation
Memory
Attention
Intelligence
Documentation:
Neurobehavioral Status Exam
• Attention
• Memory
• Visuo-spatial
• Language
• Planning
DPH 2004
Documentation: Testing
• Names of Tests (including edition/version)
• Interpretation of Tests (narrative; possibly
quantitative)
• Disposition
• Time/Dates
– In Hours (rounded to nearest hour)
– Document on Day Service is Provided
– Might be Best to Separate from Interview
DPH 2004
Documentation:
Intervention
• Reason for Service
• Status
• Intervention
• Results
• Impression
• Disposition
• Time
DPH 2004
Documentation:
Suggestions
• Avoid Handwritten Notes
• Do Not Use Red Ink
• Avoid Color Paper
• Document On and After Every Encounter,
Every Procedure, Every Patient
• Review Changes Whenever Applicable
• Avoid Standard Phrases
DPH 2004
Documentation: Ethical Issues
• How Much and To Whom Should
Information be Divulged
• Medical Necessity vs. Confidentiality
• HIPAA vs. Documentation
DPH 2004
Time
• Defining
– Professional (not patient) Time Including:
• pre, intra & post-clinical service activities
• Interview & Assessment Codes
– Generally use hourly increments
– For new codes, use 15 minute increments
• Intervention Codes
– Use 15, 30, or 60 minute increments
DPH 2004
Time: Definition
• AMA Definition of Time
• Physicians also spend time during work, before,
or after the face-to-face time with the patient,
performing such tasks as reviewing records &
tests, arranging for services & communicating
further with other professionals & the patient
through written reports & telephone contact.
DPH 2004
Time (continued)
• Communicating further with others
• Follow-up with patient, family, and/or
others
• Arranging for ancillary and/or other
services
DPH 2004
Time: Defined Further
• Evaluation Versus Therapy Time
– Therapy is Essentially Face to Face
– Testing is Essentially Professional Time
• Inpatient Versus Outpatient
- If Outpatient: face to face only for E & M
- If Inpatient: time on floor for E & M
DPH 2004
Time: Testing
• Quantifying Time
– Round up or down to nearest increment
– Testing = 15 or 60 (probably soon 30)
• Time Does Not Include
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–
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Patient completing tests, forms, etc.
Waiting time by patient
Typing of reports
Non-Professional (e.g., clerical) time
Literature searches, learning new techniques, etc.
DPH 2004
Time (continued)
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•
Preparing to See Patient
Reviewing of Records
Interviewing Patient, Family, and Others
When Doing Assessments:
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Selection of tests
Scoring of tests
Reviewing results
Interpretation of results
Preparation and report writing
DPH 2004
Reimbursement History
• Cost Plus
• Prospective Payment System (PPS)
• Diagnostic Related Groups (DRGs)
• Customary, Prevailing & Reasonable (CPR)
• Resource Based Relative Value System
(RBRVS)
DPH 2004
Relative Value Units: Overview
• Components
• Units
• Values
• Current Problems
DPH 2004
RVU: Components
• Physician Work Resource Value
• Practice Expense Resource Value
• Malpractice
• Geographic
• Conversion Factor (approx. $34)
DPH 2004
RVU: Values
• Psychotherapy:
– Prior Value =1.86
– New Value = 2.0+ (01.01.02)
• Psych/NP Testing:
– Work value= 0
– Hsiao study recommendation = 2.2
– New Value = undetermined
• Health & Behavior
– .25 (per 15 minutes increments)
DPH 2004
RVU: Acceptance
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Medicare
Blue Cross/Blue Shield 87%
Managed Care 69%
Medicaid 55%
Other 44%
New Trends:
– RVUs as a Model for All Insurance Companies
– RVUs as a Basis for Compensation Formulas
DPH 2004
CPT x RVU
CPT
Code
Work
Value
Practice Malpractice
Expense Expense
Total
RVU
Mutually
Exclusive
90801 2.80
1.14
0.06
90806 1.86
0.75
0.04
4.00 90802, 90846, 90847,
90853, 99291, 99292
2.65 90801 (?)
96100 0
1.67
0.15
1.82 96110, 96 115
96115 0
1.67
0.15
1.82 - // -
96117 0
1.67
0.15
1.82 96110, 96111
96150 0.5
0.2
0.02
96152 0.46
0.18
0.02
0.72 96151, 96152, 96153,
96154, 96155
0.66 96150, 96151, 96153,
96154, 96155
DPH 2004
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Current Problems
Definition of Physician
Incident to
Supervision
Face-to-Face
Time
RVUs
Work Values
Qualification of Technicians
Practice Expense & Testing Survey
Payment
Prospective Payment System
Skilled Nursing Facilities
Provider Based Facilities
DPH 2004
Focus for Fraud & Abuse
Current Problems: Highlights
• Work Value for Testing Codes
• Provision & Coding of Technical Services
(e.g., who is qualified to provide them)
• Mental vs. Physical Health
DPH 2004
Problem: Defining Physician
• Definition of a Physician
– Social Security Practice Act of 1980
– Definition of a Physician
– Need for Congressional Act
– Likelihood of Congressional Act
– The Value of Technical Services of a
Psychologist is $.83/hour (second highest
after physicist)
– Consequence of the preceding; grouping with
2004 health providers
non-doctoral level DPH
allied
Problem: Incident to
• Rationale for Incident to
– Congress intended to provide coverage for services
not typically covered elsewhere
• Definition of Physician Extender
– How
– Limitations
• Definition of In vs. Outpatient
– Geographic Vs Financial
• Why No Incident to (DRG)
• Solution Available for Some Training Programs
• Probably no Future toDPHIncident
to
2004
Problem: More Incident to
• When is “Incident to” Acceptable:
– Testing
– Cognitive Rehabilitation; Biofeedback
– Psychotherapy
• Definition
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Commonly furnished service
Integral, though incidental to psychologist
Performed under the supervision
Either furnished without charge or as part of the
psychologist’s charge
DPH 2004
Problem: Incident to & Site of
Service
• Outpatient vs. Inpatient
– Geographical Location
– Corporate Relationship
– Billing Service
– Chart Information & Location
DPH 2004
Problem:
Incident to versus Independent
Service
• When Does Incident to Become
Independent Service
– Appearance of No Supervision
– Clinical Decisions are Made by Staff
– Ratio of Physician to Staff Time Becomes
Disproportionate
– Distance Difficulties
– Supervision Difficulties
DPH 2004
Problems:
Recent Difficulties with Incident
to
• Who Bills Incident to
– Treating Physician Bills not the Supervising
Physician
– Then, Who is the Responsible Party
• The Physician Must Treat the Patient First
• Physician Bonuses Must Tied to a Groups’
Overall Pool of Income (e.g., not referral or
possibly individual productivity)
DPH 2004
Problem:Supervision
• Supervision
– 1.General = overall direction
– 2.Direct = present in office suite
– 3.Personal = in actual room
– 4.Psychological = when supervised by a
psychologist
DPH 2004
Problem: Face-to-Face
• Implications
• Technical versus Professional Services
• Surgery is the Foundation for CPT (and
most work is face-to-face)
• Hard to Document & Trace Non-Face-toFace Work
DPH 2004
Problem: Time
• Time Based Professional Activity
• Current =15, 30, 60, & 90
• Expected = 15 & 30
DPH 2004
Problem: RVUs
• Bad News
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–
2000
2001
2002
2003
=
=
=
=
5.5% increase
4.5% increase
5.4% decrease
4.4 to 5.7% decrease ($34.14)
• Really Bad News
– Bush Administration not supportive of changing the
conversion formula
– Change Continued to Probably 2005 Depending on
Such Factors as the Stock Market (e.g., 5000)
DPH 2004
Problem: Work Value
• Physician Activities (e.g., Psychotherapy)
Result in Work Values
• Psychological Based Activities (i.e.,
Testing) Have no Work Values
• RVUs are Heavily Based on Practice
Expenses (which are being reduced)
• Net Result = Maybe Up to a Half Lower
DPH 2004
Problem:
An Artificial Practice Expense
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Five Year Reviews
Prior Methodology
Current Methodology
Current Value = approximately 1.5 of 1.75 is
practice
Deadline for New Practice Expense = 2002
– Currently in Check Due to the Ongoing Survey
• Expected Value = closer to 50% of total value at
best
DPH 2004
Problem:
Work Value of Testing
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•
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•
First Round
Second Round
Third Round
Current Round
DPH 2004
Problem: Qualification of
Technician
• What is the Minimum Level of Training
Required for a Technician?
– Bachelor’s vs. Masters
– Intern vs. Postdoctoral
DPH 2004
Problem: Payment
• Origins of the Problem
– Balanced Budget Act of 1997
– Employer’s Cost for Health Care in 2002 =
$5,000 per employee
• What Should Your Code Be Payed at?
– www.webstore.ama-assn.org-
• State Legislation
– www.insure.com/health/lawtool.cfm
DPH 2004
Problem:
Payment Problems
• Payment Reduction Software Programs
– Claimcheck (McKesson product; Cigna, PacifiCare)
– Patterns (McKesson product; United)
• Refilling
– 51% require refilling of original forms
– But, up to 60% do not follow up
• Errors
– 54% = plan administrator
– 17% = provider
– 29% = member
DPH 2004
Problem: Payment
• Use of HMOs & Third Party
– Shift in Practice Patterns by Psychiatry (14%
increase)
– Exclusion of MSW, etc.
– Worst Hit Are Psychologists (2% decrease)
• Compensation
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Gross Charges
Adjusted Charges
RVUs
Receivables
DPH 2004
Problem: PPS
• Application of PPS (inpatient rehab)
• Traditional Reimbursement
• Current Unbundling
• Potential Situation
DPH 2004
Problem:
Skilled Nursing Facility
• Consolidated Billing
• Excluded Codes in Consolidated Billing
– 96115 (Neurobehavioral Status Exam)
– 90901 & 90911 (Biofeedback)
DPH 2004
Problem:
Provider-Based Facilities
• Is Facility Located on Main Hospital
Campus or Within 35 Miles of it
• Appropriate Reporting Relationship Exists
Between Hospital and Clinical Staff
• Medicare Cost Report Includes Facility
• Records are Fully Integrated
• Facility is Presented to the Public as Part
of the Hospital
DPH 2004
Problem: Expenditures & Fraud
• Projections
– Current
• 14%
– By 2011;
• 17% ($2.8 trillion)
• Examples
– Nadolni Billing Service (Memphis)
• $5 million in claims to CIGNA for psychological services
• $250,000 fine (& tax evasion); July 12th
DPH 2004
Defining Fraud
• Fraud
– Intentional
– Pattern
• Error
– Clerical
– Dates
DPH 2004
Problem: Fraud & Abuse
• 26 Different Kinds of Fraud Types
• Mental Health Profiled
• Estimates of Less Than 10% Recovered
• Psychotherapy Estimates/Day = 9.67
hours
– Review Likely if Over 12 Hours Per Day
• Problems with Methodology;
– MS level and RN
– Limited Sampling
DPH 2004
Problem: Fraud
Office of Inspector General
• Primary Problems
– Medical Necessity (approximately $5 billion)
– Documentation
• Psychotherapy
(oig.hhs/gov/reports/region5/50100068)
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–
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Individual
Group
# of Hours
Who Does the Therapy
• Psychological Testing
– # of Hours
– Documentation
DPH 2004
Problem:
Fraud & “The Orange Book”
• Contractor Operations
– Strengthen Regional Offices Oversight
– Improve Evaluation of Fraud Unit
– Prevent Duplicate Payments for Same Service
• Hospital Operations
– Identify Patterns of Aberrant Overpayment
– Improve External Review of Psychiatric Hospitals
• Managed Care
– Retool Medicaid Programs for Managed Care
• Nursing Homes
– Improve Assessments of Mental Illness
– Identify Patients with Mental Illness
DPH 2004
Problem:
The “Orange Book”
(continued)
• Physicians/Allied Health Professionals
– Improve Oversight of Rural Health Clinics
– Eliminate Inappropriate Payments for Mental
Health Services
– Yet, Improve Medicaid Mental Health
Programs
DPH 2004
Problem: Fraud (cont.)
• Nursing Homes
– Identification
– Overuse of Services
• Children
• Experience
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–
California; Texas
Corporation Audit
Company Audit
Personal Audit
DPH 2004
Problem: Fraud (cont.)
• Estimated Pattern of Fraud Analysis
– For-profit Medical Centers
– For-profit Medical Clinics
– Non-profit Medical Centers
– Non-profit Medical Clinics
– Nursing Homes
– Group Practices
– Individual Practices
DPH 2004
Problem: Mental vs. Physical
• Historical vs. Traditional vs. Recent Diagnostic
•
•
•
Trends
Recent Insurance Interpretations of Dxs
Limitations of the DSM
The Endless Loop of Mental vs. Physical
• NOTE: Important to realize that LMRP is almost
always more restrictive than national guidelines
DPH 2004
Problem: HIPAA
• Health Insurance Portability and
Accountability Act
• Ethics versus Practicality
DPH 2004
Possible Solutions:
General Approaches
• Better Understanding & Application of CPT
• More Involvement in Billing (especially in large, medical,
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•
multidisciplinary, and academic settings)
Comprehensive Understanding of LMRP
More Representation/Involvement with AMA, CMS,
& Local Medical Review Panels
Meetings with CMS
Survey for Testing Codes
APA: Increased Staff & Relationship with CAPP
DPH 2004
Possible Solutions: Resources
• General Web Sites
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www.nanonline.org/paio
www.cms.org (medicare/medicaid)
www.hhs.org (health & human services)
www.oig.hhs.gov (inspector general)
www.ahrq.gov (agency for healthcare research)
www.medpac.gov (medical payment advisory
comm.)
– www.whitehouse.gov/fsbr/health (statistics)
– www.div40.org (clinical neuropsychology div of
apa)
– www.healthcare.group.com (staff salaries)
DPH 2004
Resources
(continued)
• LMRP Reconsideration Process
– www.cms.gov/manuals/pm_trans/R28PIM.pdf
• Coding Web Sites
– www.aapcnatl.org (academy of coders)
– www.ntis.gov/product/correct-coding (coding edits)
• Compliance Web Sites
– www.apa.org (psychologists & hipaa)
– www.cms.hhs.gov/hipaa. (hipaa)
– www.hcca-info.org (health care compliance assoc.)
DPH 2004
Future Perspectives
• Income
– Steadier (if economy does not further
erode)
– Probable incremental declines, up to 1020%
– If Medicaid dependent (25% or more),
then declines could be even higher
– Possible “final” stabilization by 2005
• Recognition
– Masters Level Psychotherapy?…
DPH 2004
Future Perspectives
(continued)
• Paradigms
– Industrial vs. Boutique/Niche
– Clinical vs. Forensic
– Mental Health vs. Health
– Existing vs. Developing
DPH 2004
Future Perspectives
• Evolving Paradigm = Continued and
Significant Change
ARE YOU READY?…
DPH 2004